(p. 1) Introduction: The Pandemic
In 2020 the world suddenly and seemingly irrevocably changed. The Covid-19 virus, previously unknown, often lethal, and without a treatment, began to devastate populations around the globe. In the absence of a vaccine, societies retreated to ancient patterns of plague control, namely social distancing. This physical isolation protected individuals, kept intensive care units (ICUs) from overflowing, and limited at least the speed of infection—but at a cost.
The anti-Covid lockdown in the United States saved lives, at least in parts of the country that obeyed it. It brought with it, however, a host of problems: loss of sense of health safety, and sometimes loss of health itself; loss of daily routine, loss of social support, loss of income, often loss of job, and sometimes loss of loved ones (see Table I.1). These losses, alone and combined, contributed to the next and, we fear, enduring wave of pathology during the spread and in the wake of the Covid-19 virus. We anticipate, and seem already to be seeing,1 psychopathology on a grand scale: anxiety, depression, traumatic stress, and substance misuse. Those who haven’t died or become physically ill still suffer.
Table I.1. Losses Due to the Covid-19 Pandemic Engender Psychiatric Symptoms
Loss of security
Potentially lethal viral infection
Frontline medical and other personnel witness trauma
Fear of or actual illness ➔ anxiety, pain, PTSD, depression, anxiety
Loss of income
Anxiety about rent, food, finances
Loss of employment
Damage to career, income
Loss of loved ones
Traumatic loss; disrupted mourning rituals ➔ anxiety, depression, PTSD
Loss of routine
Disrupted social rhythms, activities, pleasures → anxiety, depression
Loss of social support
Physical distancing can mean social isolation
Social isolation → anxiety, depression
In the midst of this pandemic, our team of psychiatric researchers at Columbia University/New York State Psychiatric Institute (NYSPI) sought to provide remote (virtual, phone and internet video) treatment to patients in need. Remote therapy is itself a major adjustment for therapists used to seeing patients in person.2 And a major adjustment for patients, too. Moreover, it was unclear whether the treatment lessons we had learned from other traumatic events, such as rape, war, the September 11 attacks, and natural disasters like hurricanes and earthquakes, applied to this catastrophe. Most traumatic events are, thankfully, brief, whereas this pandemic is (as I write in May 2020) already a siege that promises to continue. Prolonged stress is more distressing and becomes more engrained than acute stress.3 The longer it continues, the worse the effects. And while the Covid-19 “plague” is an impersonal trauma, which is comparatively less distressing than interpersonal trauma,4,5 its extreme interpersonal consequences compound its damage. (p. 2)
A further layer of interpersonal malignity magnifies the effects of coronavirus. From the start of the pandemic, Americans have seen other countries, led by unifying, compassionate leaders, take orchestrated, scientifically driven steps to combat the spread of infection, with often beneficial results. In contrast, the U.S. federal government has been divisive, attacking, openly racist at a moment when racial and ethnic minorities are hardest hit, and strikingly anti-scientific. The President of the United States has recommended unproven and dangerous remedies such as injecting bleach (!) and turned wearing a mask into a political statement rather than a public health measure. The federal and many state governments have failed on many levels, for many people, their leaders pointedly ignoring and discounting a rising plague in defiance of basic medical tenets. Spike Lee made the point in his 2006 film When the Levees Broke that although Hurricane Katrina was an impersonal trauma, the failed, racist governmental response to the disaster gave it added interpersonal insult.
Amidst the pandemic, in the anticipation of a polarized national election, there has been a sudden explosion of national awareness and protest about structural racism following airings of videotaped evidence of the killings of George Floyd on May 25, 2020, and other African American men and women, by white policemen. The Black Lives Matter movement is a healthy, belated response to centuries of inequality and mistreatment, and its invigoration seems a healthy channeling of the frustrations of months of lockdown into an idealistic cause. Dealing with structural racism is an important cause, albeit not the focus of this book. Nonetheless, all this change adds to the turmoil in the environment individuals face.
(p. 3) Moreover, this is only the first wave of virus, and first aftershock of psychiatric symptoms. If there are future waves, as it appears there may well be, they will likely compound the psychiatric sequelae. What effect will this pandemic have not only on the adults who lose their jobs, but also on their children who are evicted from their schools and separated from their friends for months on end? Even after a vaccine arrives, the psychiatric consequences of this global disaster will likely be long-lasting.
This book describes the application of interpersonal psychotherapy (IPT) to treating the psychiatric consequences of Covid-19, and more generally to any terrible social disaster. IPT is one of many psychotherapies, and it is surely not the only route to treating post-Covid psychological symptoms, but many therapists and patients may find it a particularly useful approach.6 I will explain why in a moment.
Most books on IPT have followed a research data stream. Almost every IPT adaptation for a particular psychiatric disorder has been empirically tested and shown to work before it has been disseminated. We know that IPT benefits people with major depressive disorder (MDD),7,8 bipolar disorder (adapted as interpersonal social rhythms therapy [IPSRT]),9 eating disorders,7 and posttraumatic stress disorder (PTSD).3,10,11 What we don’t entirely know is how much it helps people who develop distress, depression, or PTSD in the wake of a prolonged disaster such as the Covid pandemic. We hope that the National Institute of Mental Health, which has in recent years funded neuroscience at the expense of clinical research,12 will recognize the need for immediate clinical trials as a result of the mental health fallout of the pandemic. Nonetheless, as we await research evidence, IPT appears to be a good candidate for the psychiatric consequences of disaster. All of the treatment cases described in this book, while disguised to protect patient confidentiality, are actual presentations from the pandemic.
Why should IPT work in the setting of disaster? First, IPT has been shown to alleviate MDD and PTSD, two of the most common sequelae of traumatic life events, and to lower anxiety. Second, IPT is a life event–based therapy, using life circumstances to contextualize psychiatric crises, explain strong emotional reactions, and use understanding of those emotions to negotiate interpersonal and other life difficulties.7 The worse the life circumstances, the more understandable strong feelings become. A pandemic is surely a life event, and it brings other distressing events—unemployment, financial need, strained interpersonal relationships, etc.—in its trail. Third, IPT focuses on mobilizing interpersonal support and on repairing attachment.13,14 This makes it an appropriate intervention for a time of interpersonal isolation, when physical separation threatens to deprive individuals of needed social support.6 Social support is a key protection against anxiety, depression, PTSD, and psychic and medical vulnerability more generally.5 Fourth, the loss of daily structure contributes to people’s disorientation and discomfort during the crisis. Adding components of social rhythms therapy (from interpersonal social rhythms therapy15) can help to restore the lost structure of pre-Covid daily life.
(p. 4) People often don’t like to have strong feelings, particularly negative feelings. Because of that discomfort, they often try to minimize their feelings through intellectualization, distraction, or suppression. The Covid pandemic inevitably evokes powerful feelings, and particularly “negative” affects such as anxiety, anger, and sadness. Some of these feelings are appropriate to the situation, others excessive. A precept of IPT is that feelings are important and informative: it is better to know how you feel, and why, in order to respond to life’s situations. It’s important to recognize that painful affects can be normal: they reflect a painful environment.3 When feelings go unrecognized and detached from context, they can become a confusing additional internal pressure for an individual to struggle with.
All of these features suggest IPT as a helpful counterweight to the stresses of the pandemic.6 We are using IPT at Columbia/New York Psychiatric Institute as well as in private practice to assess its benefits, and thus far it seems quite helpful. I hope that the reader, who is likely a psychotherapist treating patients with various emotional and psychiatric responses to these painful events, will agree.
John C. Markowitz, MD
An update at the completion of the text: three months later, Covid-19 has not begun to disappear. While New York is no longer the American epicenter of the virus, more than three million Americans have already been infected, more than 130,000 have died, and the daily number of new infections is rising. We are in for a longer siege than anticipated, with growing psychiatric consequences.